Teaching Nursing Using the Ignatian Principles

When I was asked if I would like to participate in the Ignatian mentoring program, it was with trepidation that I agreed. I am a full-time doctoral student as well as a full-time faculty member. I was not sure I could give it the time it deserved or even wanted to. However, I was afraid to pass up the opportunity to delve into the Ignatian principles with Cecile Walsh and Cathy Leahy. I am fortunate that I said yes.

We were asked to incorporate the Ignatian principles into a course we were teaching in the Spring semester. The decision to incorporate this project in the Senior Seminar class was an easy one. I believe nurses naturally manifest the Ignatian principles and I wanted the senior nursing students to express how they visualize themselves using these principles as nurses.

The Senior Seminar course description is as follows:

Course Description:

This seminar course, to be taken in the last semester, focuses on the student's transition to entrylevel practice. An inspection of personal transitions within the practice of nursing is examined. This capstone course allows the student to explore the educational transition of the program and to anticipate the professional transition into practice. Professional responsibilities of the holistic nurse are reviewed. Concepts emphasized relate to the nurse as an instrument of healing engaged in a transpersonal human caring process, self care, care of the environment and the global community.

This description lends itself to addressing the Ignatian principles. I believe that, as the senior nursing student transitions into the work place, it is an important time to, as Father Kolvenbach states, transmit "the distinctive mark of Jesuit education" (1989). This transition period proved to be a perfect time to elicit student expressions of how one would emulate the principles in nursing practice. I hoped that leaving Xavier with this fresh in their minds would imprint the mark of Jesuit education.

I created two components to this project. First, I assigned the senior students to journal weekly on a designated Ignatian principle. They were to reflect on either how they incorporated the principle in clinical, a time they witnessed a nurse using the principle or believed they would use it when they joined the work force. I graded this as a portion of the participation grade. I periodically assessed the journaling for completion and thoughtful reflection. The class met weekly on Wednesday afternoons. I found myself looking forward to this class as their reflections never ceased to amaze me.

The second component was a group presentation. I asked them to sign up in groups of 5-6 to present one of the Ignatian principles. They were asked to present an Ignatian principle that illustrates how the nurse in the workplace uses that principle. They were also challenged to express how this principle would guide their practice.

The following are a few reflections they shared in class and in their presentations:

While discussing "Finding God in All Things," Jackie told us that the following scripture guides her when she does not feel like giving it her all. Matthew 25:35-40: "For I was...ill and you cared for me....Amen, I say to you whatever you did for one of these least brothers of mine, you did for me. She said, "So, when I am tired and do not feel like giving my all, I think of this scripture and I ask myself is this how I would give care to the Lord?" One student asked if it was okay that she say, "Finding Good in All Things" instead of God because she was not sure she believed in God. When I told her that was fine and that I wanted her to feel comfortable in exploring her beliefs, she visibly relaxed. Another student stated, "Through prayer is where I find God. I can find Him in almost every situation." "Witnessing a birth," "Not everyone has the same spirituality. Respecting that as a nurse is most important." and "A nurse finds God when she works with the poor and suffering" are a few of the comments we heard in the presentation.

When discussing what Cura Personalis means to them, "Honesty with self and others," "Nurses caring for themselves to be able to provide holistic care to their patients," "Holism," "It is the ideal." were a few of their comments. During the presentation, one student expressed that "Balancing is what Cura Personalis is all about. This is not the same as juggling. When we juggle we are bound to drop something. That something may be very important..." Another stated, "Treating others as you would like them to treat you no longer works. Instead it should be 'treat people like they want to be treated'." While another commented that Cura Personalis means "involvement" to him. He believed in the importance of remembering that patients are involved in many activities that make up who they are outside of the hospital. They are not just an entity to be cared for as if they have nothing that concerns them outside of being a patient.

One student's reflection on Discernment was that seeing patients and friends making bad decisions with negative consequences has affected his decision-making. To another, Discernment is equivalent to "... the intuition that guides us". One student spoke of the vulnerability of patients making her emotional. She stated "Walking into a room seeing a patient making the decision to use an incentive spirometer after I taught him the importance of it makes me emotional. It makes me so happy." Still another expressed that Discernment meant making a difference by making the right decision.

The group who presented Magis expressed it with the mantra that "The Sky Is the Limit." They presented quotes from famous achievers who have strived and reached their goals. The students were not at a loss for words when we discussed this principle. They stated that "using evidenced based practice," "achieving goals," "staying curious," "challenging self," and "surrounding yourself by people with the same values and expectations from life" were their visualization of what Magis means.

The Service of Faith and Promotion of Social Justice provided lively discussion. There were moments I was dismayed by what I thought were 'hardened' comments. However, I applauded their honesty. I was thrilled that it allowed me into their world so that I could impart a bit of mine. Few times when our students present their perceptions of reality, can we afford the time to delve into important issues such as this one? I feel blessed that I had the luxury to discuss this important issue with them. Comments such as "providing holistic service to patients," "faith in self is important to growth," "It's important to see the patient as a person not defined by race or religion," "promoting patient spirituality," and "praying with patients is important to me" went a long way in restoring my faith. I believed this class was equipped to provide service of faith and to promote social justice, both on which a Jesuit education is based.

The discussion and presentation about Jesuit Pedagogy included comments such as the act of "learning independence teaches one to grow." They expressed, "we are all teachers" and "teaching is what a nurse does." I loved the proclamation, "teaching is an art" and Jesuit Pedagogy means "a love for learning."

Last, the discussion about Men and Women for Others included comments about serving coworkers, being a community, and team building. They saw this principle as guiding them to be advocates for their patients. They presented that paying it forward means serving others. One student discussed the importance of being open-minded if you are a man or woman for others. It was with unanimous agreement that this principle was the definition of nursing. They believed that nursing is a vocation, a calling. "You do not choose it, it chooses you." I had a student come to my office after class as she had something she wanted to add to the discussion of this principle and was too emotional to do so in class. She related a story about her uncle recently dying and her young cousin reminding his mother as she struggled to allow people to help her that it is important to be a receiver. This student emoted "The Jesuit ideal can be taken at face value as simply "doing" for others - being a servant - but isn't it just as important to allow others to do for us? This is at times "doing". Being a receiver can be just as valuable as being a giver."

As I reflect on the experience of being in the Ignatian Mentoring program, I am reminded of what I teach my novice nursing students. I teach them that they "Stand on holy ground" when they are afforded the privilege to care for the sick, the vulnerable. Equally, I have come to believe that as an educator I too stand on holy ground, as it is a privilege to be a part of my students' journeys. This experience has served to engrave that belief in my heart. I will forever remember my students' willingness to expose their vulnerability each Wednesday in our classroom discussions. Likewise, their thoughtful reflections regarding how the Ignatian principles will guide their nursing practice have influenced my own practice and will not soon be forgotten.

I joined the Xavier faculty family in the fall of 2005. This year marked a new venture for the Nursing program at Xavier. The nursing department launched their new nursing program called MIDAS. The program allows students who have an undergraduate degree in a non-nursing discipline to seek a graduate degree in nursing. I was assigned to teach the fundamentals nursing lab practicum, the second semester medical-surgical clinical, and to facilitate preceptor experiences in both the psychiatric and complex care clinical areas.

The MIDAS students come with a wide variety of backgrounds including but not limited to theology, social work, journalism, Spanish, physical education, early childhood education, social work, and geology. Both my concern and my challenge was to teach nursing fundamentals to students who had no background in nursing and to lay the foundation that would prepare them to fully accept the role of a professional nurse. A person might ask how is this program different from the traditional nursing program? The traditional program takes four years to complete. The MIDAS student is a full-time student for only nineteen months, terminating with a master's degree in nursing science and developing the knowledge base that will allow them to sit for board licensure as a registered nurse.

In 2005, I was invited to participate in the faculty Manresa retreat. It was here that I began to understand the impact of Ignatian values and principles on my role as a professional educator and as a member of the Xavier community. During the discussion of cura personalis, my thoughts immediately jumped to the MIDAS students. It was at this time I made a conscious decision to focus on the gifts the MIDAS students brought from their initial degree discipline, and not on their lack of nursing knowledge.

In collaboration with my mentor, a discernment process took place. We met and discussed my observations of the class and how I thought Ignatian principles were being integrated. I thought back to the discussion of the gift of the person. As novice nursing students, the students tend to focus on what they do not know and forget what talents and knowledge they actually possess. My goal was to design a project that gave the students an opportunity to reflect on their gifts and not their deficits. My Ignatian project was incorporated into NURS 565.

One of the course assignments is a group project that promotes collaboration of the student nurse team with the manager of the hospital clinical unit. The students in collaboration with the manager identify a quality improvement issue. The students and manager with faculty approval, decide on the project focus. Within the assignment the students identify the purpose of their project, provide research to support their actions, present a plan to implement their intervention, and describe a mechanism to evaluate the effectiveness of their project.

To incorporate the cura personalis principle, the students were to submit a self reflection identifying what knowledge, talent, or gift they contributed to the project that was reflective of their initial degree or life experience. They are also asked to identify how this knowledge or talent would be complimentary with nursing process and/or the professional development of nursing.

The reflections were amazing and at times unexpected. The following are some of the personal reflections that I would like to share:

I really enjoyed working on this part of the project. It was terrific hearing what things my fellow classmates had done. I learned a lot about them as a person.

I liked working with other professionals. I am amazed at the talent in nursing.

I did not think anything I had done before had anything to do with nursing, now I know that is not true.

I am amazed that something I learned in geology could actually be appled to nursing process.

Nursing process is very similar to scientific process. I like that there is a logical way to solve problems.

My degree in journalism really helped with condensing information for the poster.

A background in education really helped with this. I was able to share that at the meeting with the manger when we talked about learning styles.

I was able to utilize my Spanish language education and develop a hand-out in Spanish.

I really enjoyed working with the second year MIDAS student. I can appreciate the program and it was good to speak with someone who went through the program and survived. I think I found a new friend.

This really made me stop and think. It was nice to think of something positive I did.

We all worked very well as a team and we all had something very positive to give. It was fun to see everyone step up and take charge of their part.

I learned a lot about my fellow classmates.

My research came in handy when teaching others about infection control.

I have presented to large groups, so I think that really helped me to present the staff education part of the project. I was very confident.

Overall evaluations of the self-reflection component were very positive, and I feel that the goal to recognize personal gifts as well as the gifts of others was met. This component will become a permanent part of the project assignment.

In conclusion, I would like to share my analogy of a gift box. The discipline of nursing provides the framework and knowledge base that forms the foundation of nursing practice. The Jesuit principles represented by the ribbon connect us to our students, our peers, our clients, and to the world in which we live. The students are represented by the multiple loops of the bow. Just as the loops go in multiple directions, represent different sizes, and appear at different levels, so do our students. However, the loop is continuous, leading back to the Jesuit principles that guide our interactions with others, and to our nursing heritage that provides direction for excellence in practice, making us nurses and nurse educators serving others for the greater glory of God, while recognizing the gifts each person adds to this package we call nursing education.

The Ignatian Mentoring Program provided the opportunity in the fall of 2006 for me to spend dedicated time with my friend and colleague, Cecile Walsh. Because Cecile mentored two people, I was fortunate in that I was also able to share this experience with Kelly Beischel a friend from the School of Nursing. I gained an even greater appreciation of Ignatian spirituality through our discussions. As a result of this sharing I chose to incorporate Ignatian characteristics into the curriculum through journaling which would serve as a strategy for 60 junior year nursing students and six faculty members to reflect on how they incorporate Ignatian characteristics into their daily living.

Journaling is a method frequently discussed in nursing and educational literature as an "active learning technique that is meant to enhance reflective practice" (Blake, 2005). Reflective practice is a means of self-examination that involves looking back over what has happened in practice in an effort to improve, or encourage professional growth (Ruth-Sahd, 2003). Why is journaling important? The literature cites numerous reasons for utilizing journaling/reflective practice in the academic setting. According to Pinkstaff (1985), students find that ideas become clearer when they must write them down. Students get a better sense of the whole as they view their own actions embedded in the complex interactions between self and others (Cooper, 1991). Writing requires students not only to make connections, but to declare them in concrete form. Students are thereby involved actively in the process of their own teaching/learning (Pinkstaff).

Since the nursing students at Xavier already engage in reflective journaling in all of their practicum courses, it occurred to me to ask the question "could reflecting through journaling on Ignatian characteristics advance the integration of these spiritual characteristics into the everyday living"? It is from this platform that I included criteria in the syllabus for both NURS 373 and 361, in addition to the existing journaling framework, for weekly reflection on the personal application of Ignatian characteristics. During orientation to the course, each student was presented with two documents; Do You Speak Ignatian? and Student Life in the Jesuit Tradition. The objective of the weekly assignment was discussed by the faculty and students. The journaling activity was worth ten percent of the final grade for both courses.

I was hopeful that as discussed by Blake (2005) regarding the many advantages of journaling as a means of developing reflective practice that these students and faculty would experience a heightened awareness that includes the following:

Discovering meaning

Instilling values of the profession

Gaining perspectives of others

Developing affective skills

Caring for self (page 2)

Witherall (1991) states that journaling enables the writer to discover connections between self and other barriers to understanding, and to know more deeply about the meanings of one's own cultural narrative. Journaling provides a form of educational encounter that renders us human and frees the moral imagination.

Below are some of the quotes excerpted from over 500 journal entries. Student excerpts:

"Ignatian principles and characteristics work really well with holistic nursing"

"I've actually never been asked to include Ignatian principles/characteristics into my care and truthfully have never thought about it while I was caring for someone. But, I've always tried to keep a positive attitude about what I'm doing even though I'm nervous. I do my best to stay respectful of the patient and others on the unit by talking calmly in the hallways and addressing needs for the patient at the first available opportunity. If students need help, I assure them everything will be ok because we are all in this clinical journey together."

"The Ignatian principle that I witnessed today was seeing "good" in the universe and being grateful for the gift. The entire surgery staff seemed really aware of respecting the patient and wanting to provide the best care possible. They respected each other and the roles they each played in the surgery as well. When I went to the PACU, I also saw this respect for the patients. The nurses were with them the whole time, giving them support as they came out of anesthesia. It gave me a positive feeling to see this consistently happening."

"Discernment and 'magis' are two Ignatian principles I have been thinking about lately. As a nurse (and also just a person in general), I always hope to make good decisions. In the nursing profession, it is especially important to make decisions that are good for clients and staff. Making good choices is not always easy because of the number of factors to consider or the nature of the issue (legal/ethical dilemmas). The idea of "magis" has become a challenge for me. I try to push myself beyond basic expectations in the classroom, at clinical and also other areas of my life. I have found that the highest expectations I encounter are the ones I have for myself. My hope is that these expectations will help me to always strive for excellence, for more."

"I found God in all things with my patient. Although she was grumpy at first, I was able to be patient and help her have less pain. I did not become angry with her, but I understood and tried to put myself in her position."

"I told my patient everything that I was doing, held her hand, and sat with her in hopes that she would feel less anxious and more like an individual of importance. I did not yell at her like I heard someone else do, I really wanted her to feel like a respected human being. I see this as women and men for others not just doing what I am supposed to do as a student nurse."

"I feel that this clinical experience has opened my eyes wider to the Ignatian principle of being 'men and women for others.' Through my interactions with the nurses, my fellow classmates and Shannon, I have come to realize that this is our main purpose in life, to be 'men and women for others.' As a nurse, I will get this opportunity everyday."

Faculty response:

"I think the principle of "magis" can be a double-edge sword. In striving for more or excellence, it is sometimes hard to know when enough is enough. Over the last couple of weeks, I have had two students that have been very hard on themselves, in terms of grades on assessments, written in their journals or verbalizing frustrations that they were not more independent, functioning at a higher level or getting better grades. While I can certainly understand their striving for more or excellence (which I do encourage), I have tried to impart that this time in their education, is a time for learning and growing. It is unreasonable for them to expect to have mastered all those skills at this time. I don't want them concentrating only on the negative, I am trying to get them to acknowledge the significant advances they have made and will continue to make throughout the remainder of their education. I believe that I encouraged caring for self or 'Cura Personalis' through my reflections."

In conclusion, the assignment of weekly reflective journaling upon personal application of the Ignatian characteristics for many was a meaningful experience. I valued the opportunity to witness growth in awareness and understanding over time and most students agreed that the assignment should be included in subsequent years. As described by Cooper (1991) "these small, insignificant objects, filled with the simple words of our lives can serve to make us whole."

Community Nursing Practicum (NURS 443)

Cecile Walsh, MSN, RN, CNSMentor: Ginger McKenzie, Ph.D. (Education)

In the Fall of 2004, being a member of the Ignatian Mentoring Program, I was given the challenge of integrating the Ignatian mission into a course that I would teach in the Spring semester. I chose the course NURS 443, Community Nursing Practicum. This course is unique to the university in that it is a "bridge" course. In the School of Nursing we refer to courses that segue a registered nurse (RN) without a college degree into master level courses as "bridge" courses. The typical student in this course has an RN license from a diploma nursing program or associate degree program. Often the student is middle aged as will be evident in the student profile that follows. I chose this group because the required course is offered before these students begin graduate work and therefore occurs early in their years at Xavier. I also chose this group because they are adult learners. Adult learners are always challenging and I believed that they may not have been exposed to the Ignatian mission.

As the syllabus states, Community Nursing Practicum focuses on health care management and various nursing roles within communities of increasing complexities. Nursing strategies aimed at disease prevention, promotion and restoration of health are applied to the management of identified community health problems. This course is a co-requisite with Nursing and Community Health (NURS 442). The course objectives involve using epidemiological methods to describe the state of health of a community; implementing problem solving processes to design resolutions for identified community health problems; enacting the role of a community health nurse in selected settings; and analyzing interpersonal communication patterns with various groups. In reality, the student chooses an aggregate within the community. Through an assessment process, the student determines a health care need within the aggregate. After research, the student develops a plan of care and implements and evaluates its effects. An additional requirement - due to the professor's philosophy- involves a service component. The aggregate must be chosen by the student on the basis of having unmet needs, largely due to financial limitations. Evaluation methods include participation in seminar discussion, practicum logs, and a written paper discussing the project.

So how might one integrate Ignatian mission into a community nursing course? NURS 443 was an ideal course in which to integrate a mission driven teaching component. Each student was working with a group in the community and the course had a service theme. A profile of the students helps to illustrate their receptivity to this project. For the Fall semester, NURS 443 consisted of 10 adult learners. They were all female ranging in age from 40-55 years. Their years of nursing experience ranged from 13-31. The students' areas of nursing expertise included emergency room, surgery, ICU, research, cardiac, pediatric, and oncology nursing.

The purpose of the mission driven teaching component was to familiarize the graduate student with the Ignatian way and promote an understanding of Ignatian values. Adult learning principles were utilized. The student was assigned to read "Cura What?" This booklet, written by Patricia Marik and Debra Mooney, is a graduate student's guide to understanding and living the Jesuit mission. When the student returned to seminar, each component of "Cura What?" was discussed. The components of the booklet cover cura personalis, discernment, finding God in all things, men and women for others, magis, and the service of faith and promotion of social justice. After self-reflection, each student shared how she integrates principles of the Ignatian mission into her life and her proposal to implement the mission in her project. The last aspect of this assignment entailed writing a short paper discussing the implementation of the mission.

The seminar discussion was enlightening. Author Debra Mooney was able to join the class for observation and input. The scholarly papers also offered insightful comments by the students. The following quotes are excerpted from the written papers and seminar discussion.

Integrating the Jesuit mission into my clinical experience and project was a natural fit. In my 30-years plus as a nurse I have implemented all of the Jesuit values outlined in "Cura What?" without even knowing they were Jesuit values.

In Cura Personalis it is clear that Xavier is driven to shape its students as a whole individual, not merely intellectually. This can be a difficult piece to integrate into my own life. I have always been the major money maker, taking care of the children and other family members while going to school. I often lose sight of taking care of my own self, body, soul and mind. However, after I made the decision to return to college, it has been extremely refreshing and supportive, that the Xavier staff respect and acknowledge my personal and work life. This environment allows graduate students to provide and care for either families as well as their education.

Discernment: As a nurse who cares for premature infants, there are often several possible courses of action, all of which are potentially good and you must choose the best option for each individual infant as what is good for one infant many not be good for another.

The community project practicum brought me much discernment. I could have made it easy on myself and chose a path that had already been taken, but in my heart, I felt pulled in a different direction. Deciding to start and implementing a support group for adolescents who self-injure was not an easy decision.

As a nurse, I believe I have a gift for seeing good (God) in all things and in all people. I believe all persons have some good in them. I believe God is always present with us in our lives; I also believe all things happen for a reason. Seeing the good in all persons is really a gift; a gift of patience and understanding.

I have always felt that challenged children, no matter the source of the difference, possess a gift from God. A child's gift from God to others may be simply that they enrich the lives of those with whom they come in contact thereby offering a glimpse of Christ known to be found in everyone.

Finding God in all things: a smile from a patient, a compliment from the family, or a satisfied feeling when I know I have done my best at the end of a very long day, even if I did not get everything done.

Men and women for others: I feel that nursing for me has always embodied this ideal and what nursing is all about: a mission and service to the community. I do not really think most individuals would continue to stay in this field just for a paycheck. The work is too difficult and demanding. There has to be something more spiritually and psychologically driving most individuals to stay in it.

Striving for excellence, or magis, is the foundation of my clinical experience. It is truly refreshing to discover that there are many new things to learn...even after age 50. The feedback I have received in class and in my log entries has helped me to think more about what I'm doing and how to do it. As I have challenged myself to think about my project, I have revised my plan several times in an effort to "strive for more."

I have been raised with many of the Jesuit values such as you must see God in all things and you cannot tolerate social injustice towards people. If you can bring about a change, do so in a non-violent way that brings God the Glory. I was raised in an activist household, every Sunday after church we would listen to Martin Luther King speeches and had to reflect on them. The Jesuit mission enforces many of these values to me and helps to bring everything in my life in perspective. We, as students, are here to learn at a scholarly level and also to gain understanding of how to serve the community better with our enhanced knowledge.

In conclusion, the assignment of integrating the Ignatian mission into a course was very beneficial to the student and the professor. During discussion all students agreed that the assignment should be included as part of the course in future years. The assignment instigated a self reflection by the student that would not have occurred otherwise.

Paper presented at the Nurse Educator Institute, Branson, MO, March 31-April 3, 2009 and at the Association of Community Health Nurse Educators National Conference, Chicago, IL, June 11-13, 2009.